Emergency Dental Treatment Consent Form

 

COVID-19 Pandemic Emergency Dental Treatment Consent Form

 

I, _______________________________________, knowingly and willingly consent to have emergency dental treatment completed during the COVID-19 pandemic.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. It is impossible to determine who has it and who does not given the current limits in virus testing.

Dental procedures create water spray which is how the disease is spread. The ultra-fine nature of the spray can linger in the air for minutes to sometimes hours, which can transmit the COVID-19 virus.

I confirm that I am not presenting any of the following symptoms of COVID-19 listed below:

 

I understand that air travel significantly increases my risk of contracting and transmitting the COVID-19 virus. And the CDC recommends social distancing of at least 6 feet for a period of 14 days to anyone who has, and this is not possible with dentistry. ___________ (Initial)

 

Signature____________________________________                            Date____________________

Author
Meng Syn DDS Partner at Almaden Dental Associates

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